How best to get patients to take pills

MEDICAL MATTERS: I first became aware that patients did not always take their medication when, as an intern, I was presented with a plastic bag full of tablets by relatives of a patient who had just died.

Their concern was to dispose of the medication safely; I reflected on how much the lack of compliance with heart, blood pressure and breathing tablets had contributed to the person's recent admission and subsequent death.

But it wasn't until I had to take medication for a chronic illness myself that I realised how hard it is to remember to take tablets on a regular basis.

Even loading the tablets into a multi-compartment box with a section for each day of the week and specific times in each day has not ensured that I am fully compliant with the treatment regimen.

Sometimes one or two compartments remain full as I reload for the following week, a reminder that, despite my best efforts, remembering to take all of the tablets all of the time is a considerable challenge.

It is estimated that only about half the people who leave a doctor's surgery with a prescription takes the drug as directed. The commonest reason is forgetfulness. But why do people forget?

The psychological mechanism of denial could be at work: having a disorder is upsetting and having to take drugs is a constant reminder of your illness.

Or the patient may not have "bought in" to the prescription during the consultation with the doctor. He may be concerned about particular side effects, and is therefore reluctant to take the medication.

Research published in the Archives of Internal Medicine last year found that patients with diabetes who trust their doctor are more likely to stick to their prescription medicines. And people with diabetes and symptoms of depression were twice as likely to skip taking tablets, perhaps because it made them feel fatalistic about their diabetes.

Emphasising the importance of communication with patients if compliance with treatment is to be maximised, the lead author of the study said doctors must actively reach out to establish trust with their patients.

A strong therapeutic bond is more likely if the doctor and pharmacist provide clear explanations about how to take the drugs, why they are necessary and what to expect during treatment. And people are more likely to comply if they believe the healthcare practitioner really cares whether they follow the treatment plan.

Communication is, of course, a two-way process. By asking questions, patients can weigh the advantages and disadvantages of the treatment.

Practical issues, such as when and what dose of medicine to take, need to be clarified. Ask how long you should take the medication and ask about possible side effects.

It has been shown that 15 minutes after a consultation has ended, patients have forgotten 50 per cent of the information they were given, so don't be afraid to ask for written instructions or to call back for clarification.

Other reasons for not complying with drug treatment include anxiety about the cost, misinterpreting the instructions, stopping the drug too early (this frequently happens with short-term prescriptions of antibiotics for infections) and even having difficulty opening the tablet bottles.

European research carried out by the International Osteoporosis Foundation (IOF) found that 60 per cent of women who were prescribed a once-weekly dose of biphosphonate (a bone-saving medication) stopped taking it after a year. But perhaps the most interesting finding was that most women felt that if doctors focused on the positive outcomes of treatment, it would be the greatest motivation for continuing therapy.

In an effort to improve compliance with medication, various strategies have been tried. A doctor in South Africa, David Green, has improved compliance among his TB patients by introducing a text messaging service to remind them to take their medication.

TB treatment lasts for up to a year; poor adherence results in a low cure rate and a rising incidence of multi-drug resistant tuberculosis. The computer in the Cape Town clinic automatically sends personalised messages to patients.

When they complained the messages were boring, Dr Green included jokes and lifestyle tips. Of the 300 TB patients involved in the pilot scheme there were only five treatment failures in total. You could use the alarm on your own mobile phone to send medication reminders to yourself.

Drug companies offer slow release versions of drugs which can reduce the daily schedule from four times to once a day. And biphosphonate, the osteoporosis treatment, is now available in a monthly dose.

Finally, don't worry about missing the occasional tablet - I don't.

Dr Muiris Houston is pleased to hear from readers but regrets that he cannot answer individual queries.